Endometriosis of Nongynecologic Organs and Extrapelvic Sites
M. Jean Uy-Kroh
Tommaso Falcone
General Principles
Definition
Endometriosis is the presence of ectopic endometrial glands and stroma. Disease involvement is diverse and may be superficially limited or deeply infiltrative into organ systems such as the gastrointestinal and urinary tracts and the respiratory and musculoskeletal systems.
Differential Diagnosis
Benign neoplasm
Malignant neoplasm
Overactive bladder
Painful bladder syndrome
Irritable bowel syndrome
Inflammatory bowel disease
Myofascial pain
Nonoperative Management
Nonoperative management includes hormonal suppression with oral contraceptive pills, progestin therapy, or Levonorgestrol secreting IUD, gonadotropin-releasing hormone agonists, and off-label use of aromatase inhibitors. These treatments may provide symptomatic pain relief and reduce the size of lesions. However, even with optimal medical therapy many patients remain symptomatic due to fibrosis and infiltrating disease. Physical therapy and pain management procedures may also alleviate symptoms. Refractory pain and the uncertain neoplasm etiology lead many patients to undergo surgical resection and histologic confirmation of nonmalignant endometriosis.
Bladder endometriosis warrants a trial of medical management. If there is a concern for obstructive uropathy, nephrostomy tubes and ureteral stents may also be used. Surgery is indicated for symptomatic patients who suffer from extrinsic obstruction, have contraindications to medical management, or who would benefit from ureteroneocystotomy.
Bowel obstruction, ureteral stenosis, and pneumothorax caused by endometriosis implants typically require urgent surgical management in addition to palliative procedures (nasogastric tube, ureteral stent placement, and chest tube), concomitant medical management, and monitoring of electrolytes, kidney, and respiratory function.
Postoperatively, we recommend continued hormonal suppression, no matter the disease location, and continue this therapy long term.
One cautionary note: Asymptomatic patients with histologically confirmed endometriosis and extrapelvic or nongynecologic disease do not require surgical treatment and may be medically managed. Those with advanced disease may be followed with imaging if there is concern for advancing invasive disease.
Conversely, a symptomatic patient without histologically confirmed endometriosis and imaging suggestive of endometriosis lesions must undergo a laparoscopic tissue biopsy at the very minimum to confirm the endometriosis diagnosis. The patient’s quality of life, comorbid conditions, and lesion’s mass effect should all be considered prior to surgical resection. It is crucial to confirm the endometriosis diagnosis by tissue pathology to avoid inappropriate medical management of a malignant neoplasm.
Imaging and Other Diagnostics
Tumor markers such as CA125 are often elevated in patients with endometriomas. Therefore, we do not recommend this serum testing for a patient with known deep endometriosis extending more than 5 mm into the peritoneum and lesions with characteristic appearance of extraperitoneal endometriosis.
Perform preoperative cystoscopy to assess bladder mucosal involvement if suspicious for this by the patient’s history.
Small-bowel endoscopy and colonoscopy rarely reveal transmural or mucosal endometriosis but may be useful to evaluate for differential bowel diseases, suspected malignancy, or bowel strictures secondary to endometriosis.
Transvaginal and abdominal ultrasound can detect rectosigmoid and bladder endometriosis. This imaging requires experienced sonographers and a high level of radiographic expertise.
Computed tomography (CT) is only useful for pelvic mass evaluation and ureteral obstruction but it is not useful for pelvic soft tissue evaluation. Instead, we prefer Magnetic Resonance Imaging (MRI), with enterography, for preoperative soft tissue evaluation (Figs. 13.1 to 13.4).
Preoperative Planning
Patients with anterior abdominal wall disease can be examined easily in the office. Patient discomfort and habitus, however, may limit the utility of this examination.
A rectovaginal examination should be performed to determine the presence of tissue thickening, masses, and nodularity. If the patient can tolerate a bimanual examination, this can also yield useful information such as a fixed, retroverted uterus, irregularity or tenderness of the posterior cul-de-sac and vaginal fornices.
Occasionally, a speculum examination reveals pigmented endometriosis lesions that may be easily biopsied. Lesions that are deep to the vaginal mucosa should not be aggressively biopsied in the office as they may communicate with the rectum.
Figure 13.1. Endometriosis nodule of the bladder, MRI.
We strongly advise referring these patients to a tertiary center with surgical experts experienced at managing nongynecologic endometriosis in an interdisciplinary fashion. Although endometriosis may present in anatomic locations that are surgically unfamiliar to gynecologists, it is important not to treat this benign, albeit tenacious, disease as an oncologic subset. Doing so places the patient at risk of decreased fertility, unnecessary intervention, and increased surgical risks. Surgical treatment is peppered with a myriad of known complications, many of which can be fatal if mismanaged. Even after successful surgical treatment, patients often require ongoing medical and ancillary treatments to abate the sequelae of their disease.
Figure 13.2. Right obstructive hydronephrosis, CT urogram.
Figure 13.3. Obliterated cul-de-sac and spiculated endometriosis lesion, rectocervical disease, MRI.
The comprehensive medical and surgical management of patients suffering from extraperitoneal endometriosis should only be undertaken at large centers with the personnel and resources capable of providing complete care for the patient.
Interdisciplinary treatment teams may include surgeons and physicians from urology, colorectal/general surgery, gastroenterology, plastic surgery, cardiothoracic surgery, physical therapy, and pain management.
The goal of surgical extraperitoneal endometriosis management is to remove endometriosis and fibrosis and to restore the organ’s function. Hysterectomy and salpingo-oophorectomy may also be considered depending on the age and desired future fertility of the patient.
 Figure 13.4. Rectrocervical endometriosis, MRI. |
Surgical Management
Urinary System—Bladder and Ureter
Approximately 0.3% to 6% of endometriosis cases have urinary tract involvement. Most commonly, endometriosis affects the bladder (84%), ureter (15%), kidney (4%), and urethra (4%).
Symptoms include hematuria, vesical or suprapubic pain, dysuria, urinary frequency, and back pain that may be constant or cyclical especially at the time of menses.
Imaging may reveal focal thickening of the bladder wall, edema, or a mass lesion. Cystoscopy confirms the absence or presence of mucosal involvement.
Extrinsic ureteral compression is usually due to peritoneal fibrosis. Intrinsic ureteral compression is often caused by endometriotic implants on the muscularis of the ureter.
Ureteral resection is often necessary if hydronephrosis exists.
Gastrointestinal System—Bowel and Rectum
Rectocervical or bowel endometriosis is present in 5% to 12% of endometriosis cases and usually coexists with other endometriosis lesions. The most common bowel sites are the rectum and sigmoid colon, followed by the appendix and small bowel/ileum.
Symptoms include dysmenorrhea, dyspareunia, bloating, constipation, diarrhea, dyschezia, and hematochezia.
Based on anatomic location, bowel endometriosis can be divided into two subsets: rectocervical disease and disease affecting the bowel wall proximal to the rectosigmoid.
Rectocervical disease often requires uterosacral ligament excision and/or posterior cul-de-sac adhesiolysis.
Rectal nodule or local excision may confer equal pain relief compared to segmental rectal resection and with less postoperative gastrointestinal side effects.
In general, bowel resection for endometriosis depends on the lesion size, depth of invasion, and the percentage of circumference involved. The smallest resection that eradicates the diseased area and maintains functional anatomy is preferred.
Perform a partial bowel excision (disc excision) if there is a:
unifocal lesion less than 3 cm.
lesion that involves less than 60% of the circumference of the rectum or sigmoid wall.
Perform a segmental bowel resection if there is:
deep invasion of the muscularis, or
a lesion larger than 3 cm or multiple nodules.
The posterior vaginal fornix and pelvic sidewall require concomitant dissection and endometriosis resection.
Musculoskeletal System
Iatrogenic endometriosis seeding occurs when the endometrium is breached during surgical procedures such as cesarean delivery. At that time, endometrial tissue can escape from the uterine cavity and implant along the fascia, muscle, subcutaneous fat, and other surfaces exposed during the surgery. The prevention, pathogenesis, and optimal treatment of musculoskeletal and abdominal wall endometriosis are unknown. Future areas for study include recurrence rates, optimal resection margins, and surgical techniques to decrease recurrence.
Figure 13.5. Abdominal wall endometriosis, CT abd pelvis.
Symptoms: Cyclic or constant abdominal pain often with a palpable abdominal wall mass near a prior incision or trocar site.
Seventy-five percent of patients report perimenstrual pain and have a history of cesarean delivery.
Patients usually present in their mid-30s and their last surgery may be several months to years prior to clinical presentation. The mean mass size is 4 cm and is often misdiagnosed as an incisional hernia or granuloma.
Perform CT to characterize the lesion (Figs. 13.5 and 13.6A,B).
Other Distant Sites
The enigmatic, and at times obstinate, nature of endometriosis can also affect distant sites and organs such as the diaphragm, lung, nervous and lymphatic systems. As with the pelvic counterparts, management of distant endometriosis should focus on minimizing the clinical sequelae of the disease and restoring/preserving organ function. The value of experienced, interdisciplinary surgical and medical management to yield optimal patient care is underscored.
Symptoms of thoracic endometriosis include right-sided catamenial pneumothorax hemoptysis, chest pain, and dyspnea. Some patients are asymptomatic and do not require treatment. Co-management with an experienced interdisciplinary team that includes gynecologic, thoracic, vascular surgeons and neurosurgeons for disease resection in the respective distant organs is recommended (Figs. 13.7 and 13.8).
Positioning
Approach
Preoperative Prophylaxis
We recommend all patients receive venous thromboembolism (VTE) prophylaxis commensurate with their VTE risk. Administer antibiotics within 60 minutes before the
procedure and re-dose for major blood loss or prolonged procedures at intervals equal to 2.5 times the half-life of the antibiotic.
Figure 13.6. A: Left rectus muscle seen anteriorly with spiculated endometriosis invasions into the bladder serosa, coronal, noncontrast MRI. (For intraoperative images, see Tech Fig. 13.38.) B: Left rectus muscle with poorly demarcated bladder interface, sagittal T2-weighted MRI. (For intraoperative images, see Tech Fig. 13.38.)
Figure 13.7. Right hydropneumothorax with liver herniation thru diaphragm due to endometriosis, coronal view MRI.
Urinary tract and abdominal wall procedures:
Administer 2 g Cefazolin IV for patient less than 120 kg and 3 g for patients greater than 120 kg. Redose approximately every 4 hours during the procedure.
Gastrointestinal tract:
Given variations in bowel preparation and antibiotic preferences, we recommend discussing this preoperatively with your colorectal surgeon.
 Figure 13.8. A,B: Diaphragmatic endometriosis, note the diversity of lesions. |
Procedures and Techniques: Urinary Tract Endometriosis Resection (Video 13.1)Place a uterine manipulator of choice and a three-way Foley catheter into the bladder to allow for bladder instillation if needed throughout the surgery. See Chapter 5 for basic setup and entry for laparoscopy.
Superficial bladder peritoneum resection
Grasp and sharply incise the normal bladder peritoneum (Tech Fig. 13.1).
Dissect the loose areolar tissue and underlying structures off the peritoneum and around the endometriosis implant (Tech Fig. 13.2).
Then excise the implant sharply or with radiofrequency or plasma energy.
Perform cystoscopy to confirm ureteral patency and lack of mucosal involvement.
 Tech Figure 13.1. Superficial peritoneal bladder lesion. |
 Tech Figure 13.2. Bluntly dissect loose areolar tissue. |
Deep endometriosis resection involving the bladder muscularis
An understanding of bladder anatomy is important for safe and efficient surgery (Tech Fig. 13.3).
Begin laterally and sharply dissect the underlying nonfibrotic tissue away from the implant(s) (Tech Figs. 13.4 and 13.5).
Tech Figure 13.3. Normal bladder anatomy and layers.
Tech Figure 13.4. Obliterated vesicouterine space with infiltrating endometriosis into the bladder muscularis.
Tech Figure 13.5. Sharp excision of fibrotic adhesions.
Grasp the abnormal tissue and press “toward the lesion” and not away (Tech Fig. 13.6).
Identify the correct dissection plane: the nodule’s interface to normal, healthy bladder tissue.
Push the uterus cephalad with a uterine manipulator to facilitate this plane dissection.
Once healthy tissue is encountered, bluntly dissect the tissue away from the fibrosis to minimize the loss of normal tissue and anatomy distortion (Tech Fig. 13.7).
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